Purpose: Breast cancer–related lymphoedema (BCRL) affects up to 30% after axillary lymph node dissection (ALND) and is difficult to treat, highlighting the need for preventive strategies. Lymphaticovenous anastomosis (LVA) offers a potential solution when performed at index operation. Indocyanine green (ICG) fluorescence axillary reverse mapping (ARM) has been shown to be superior to blue dye ARM, with 95% accurate lymphatic mapping based on the authors’ prior work. This study reports early technical and clinical outcomes from the first ten cases. Methodology: Consecutive patients with node‑positive breast cancer undergoing ALND received ICG fluorescence‑guided ARM followed by immediate LVA at a single institution (April–August 2025). ARM lymphatics were identified with ICG and microsurgically anastomosed to a venous tributary. Anastomotic patency was assessed intraoperatively using ICG transit. Operative details, complications, and lymphoedema outcomes (bioimpedance spectroscopy and Norman Questionnaire) were assessed at 6 months. Trial registration: ACTRN12625000414415. Results: Ten patients were included. Nine underwent a single technically successful LVA; one patient lacked a suitable recipient vein. Anastomoses used an intussusception technique, comprising eight end‑to‑end anastomoses (one requiring a jump graft) and one arborised anastomosis. Patency was confirmed intraoperatively in all successful cases using ICG. Median duration of LVA component was 50 mins (IQR 40–95). One postoperative seroma occurred; no infections or anastomosis‑related complications were observed. At 6‑month followup, no patients had developed lymphoedema. Conclusion: This pilot demonstrates feasibility and safety of ICG‑guided LVA during ALND, with high technical success, reliable intraoperative patency confirmation, and no early lymphoedema. These findings support longer‑term followup within the full prospective trial to assess durability and lymphoedema risk reduction.